Exploring the Island

My work keeps me busy for most of the time during the working week and its quite often well into the evening before I have finished researching problems on the web and writing various reports and presentations which I am expected to give. I do however have time free at the weekends and there is a small but active ex-patriot group who create a busy social life.

The weekend begins at 4:00 pm at Donny’s Bar on the waterfront and by the time I get there, usually about 5:30 the atmosphere is alive with gossip and discussing plans for the weekend. Options are a little limited on St Helena where there are virtually no organised events and culture extends to Country Music but little else. The main activities are walking in the hills and sailing or fishing. Mike and Neil are the ring leaders of the walking group and dream up theme walks, ”Breakfast at the Barn” – which I missed,” Lunch at Lots” and the next is planned to be “High Tea at High Hill”. “Lunch at Lots” was a couple of weeks ago.

“Lot” is a massive basalt pillar set on the steep volcanic slopes of the south side of the island leading down toward Sandy Bay. The latter is a complete misnomer, there is very little sand and what is there is black and stony, the bay itself is exposed to the prevailing SE trade winds with large breakers, far too dangerous to consider swimming. It was still raining when 10 of us set off from near the peaks initially through fields of New Zealand flax which was once the islands main cash crop. The flax was processed on the island to produce string for the UK Post Office. Sadly natural fibre gave way to modern synthetics and the islands main industry disappeared overnight about 30 years ago, a blow from which the island economy has yet to recover. As we descended the weather improved and landscape changed to green pastures with cattle grazing then to dry scrub and finally steep rocky slopes with little vegetation.

The path which had been a farm track higher up gradually petered out until we were struggling to find any signs of a path and finally, despite being led by an ex-Army officer with a map, got completely lost on a steep unstable slope. We retraced our steps with considerable difficulty and eventually found the cable.

The cable was a 100m length of old electricity distribution cable firmly anchored to a gnarled old tree which enabled us to abseil down an otherwise impassable rocky outcrop to reach a ridge which led to the base of Lot.”Lot’s wife” is another similar pillar about a mile away across a barren rocky landscape appropriately called “The Gates of Chaos”. It is possible to climb Lot and a small group of us started up using another length of cable, I retired after about 30m but a couple of the more adventurous members of the expedition managed to get more than half way up.

The way home was back the way we had come using the cable to haul ourselves up over the rocky outcrop and then a long steady climb back to the high plateau where we had left our cars.

The following weekend was much more relaxing, one of the group, Ann, is a keen sailor and she has bought a 36ft old steel schooner from a Saint for a bargain price. In the preceding month several of us had spent a lot of our spare time assisting with maintenance and getting her sea worthy. The weekend after Easter was our first opportunity to go for a sail. We planned to sail around the island preferably without using the engine. We met up before dawn at 5:30 on the quay, took the ferry to the mooring and were on our way as the sun appeared above the eastern horizon. After a week or two of fairly persistent rain we were blessed with a fine day and a fresh breeze.

We made good progress beating into the breeze and rounded the Barn, a massive rocky outcrop on the north eastern tip of the island, where the others had enjoyed breakfast a few weeks previously when I was working, after a couple of hours. Sailing down the eastern side of the island was slower as we were beating into a rough sea on the exposed coast Galaxy however is a well designed yacht strongly built and capable of making headway in difficult conditions.

Ann was content to enjoy her boat and left Neil and I to play with the sails to try to get the best out of her. She, “Galaxy”, has been sailed round the world before and has an interesting collection of sails to set on her twin masts. Although the wind slowly moderated we continued to make good progress with the wind on quarter as we sailed around the southern tip of the island and came up to Sperry Island.

Sperry Island is a very dramatic rocky island stack, home to thousands of sea birds who surrounded the boat and were clearly not there to welcome us. 

We had planned to anchor off the next island for lunch and a swim but sadly as we rounded South West Point the wind died away completely and for the next 3 hours we drifted slowly northwards enjoying a leisurely lunch and a bottle of wine. We delayed starting the engine until we calculated that we had no choice if we wanted to get back to our mooring before nightfall when the ferryman would head home leaving us stranded. The engine had only been running for 10 minutes.

“Phoenicia” a replica Phoenician sailing vessel which is following one of the ancient trade routes around Africa and is currently visiting the island. There is however no evidence that the Phoenicians ever came to St Helena which was discovered by the Portuguese in the 15th or 16th century. Well satisfied with our day we retreated to the Consulate Hotel to celebrate our circumnavigation. 

This coming weekend the team are going to sail around the island the other way, unfortunately I have work to do.

My working day

I have delayed writing about my work because of concerns about confidentiality. This blog is accessible to anyone who finds it and the island population is so small that it would be easy for patients to identify themselves. I shall have to be circumspect in what I write and careful not to cause offence.

I knew when I accepted this post that it would be different previous work I have done. Working as a GP in the UK I used to see a huge variety of medical problems and move rapidly from one medical speciality to another as each new patient described their problems. Indeed I often dealt with several totally different problems during a consultation with a single patient. Up to a point it is no different here, when I am working in a general clinic the work is very similar to UK General Practice. It is what happens next that is different. Whereas in the UK there is always a specialist to refer to or take advice from on St Helena there are no specialists. There are three GPs Sarel, Wendy and myself, and a General Surgeon, Ramdas, to do everything.

We do have visiting specialists, there was an orthopaedic surgeon here for a couple of weeks in January but he won’t be back for a year or two. The ophthalmologist should be coming in August but we are awaiting confirmation and we are hoping to find a General Physician, if there are any left, to come for a couple of weeks before the end of the year. It is possible to contact various specialists by e-mail or phone for advice but that is time consuming and you still carry full responsibility for managing the patient. I find myself spending a lot of time on the internet in the evenings reading up about problems I am trying to manage. My two GP colleagues are helpful but unfortunately they do not always see eye to eye and I sometimes receive conflicting advice. Sarel is good on cardiology and obstetrics and Wendy is helpful on gynaecology but in other areas we have no shared expertise at a spcialist level.

I have been given Diabetes, Elderly Care and Psychiatry as my special interest areas and run dedicated clinics. Diabetes is a huge problem on the island with nearly 1 in 3 middle aged women having diabetes. Management in the past has often been haphazard mainly I think because some of the GPs who have worked here do not have the UK approach to Chronic Illness and do not always follow guidelines on best practice. They tend to respond to problems then do little to monitor a condition until the next problem arises. The result is that less than 25% of diabetics are well managed by UK standards and many patients have complications that might have been avoided with better pro-active care. I am attempting to reorganise the diabetic clinic, introduce some simple guidelines and even audit the outcome.
Psychiatric care is rather better organised, I have the support of a UK trained CPN and a monthly teleconference with a South African Professor of Psychiatry who has been to the island and understands the working conditions and constraints we have to adapt to. The GP type psychiatry is straightforward but I also have responsibility for the small psychiatric hospital and patients with learning difficulties as well as children with ADHD and adolescents. The latter group are a particular problem as there have been a series of teenage rapes by older men with family links.  I will also be taking on the child protection work when Wendy leaves.

The General Surgeon at present is Prof Ramdas Rai from India whose interest is endoscopy and GIT tract surgery. He is excellent in his specialist field but a little reluctant to move outside it. Also of course a surgeon requires an anaesthetist and that naturally is the role of the GP. Fortunately my past training in anaesthetics and a couple of sessions of updating my skills at Salisbury before I left has enabled me to take on this work reasonably comfortably. I do a day in theatre every third week and occasional additional emergency cases. I have given about 20 anaesthetics so far without major problems - touch wood!
Emergency orthopaedics is a major weak area. I have reduced and set a couple of minor fractures. Fortunately road traffice accidents are rare and violence uncommon but the lady with a fractured femur can only be managed conservatively until the next ship for Capetown which will be nearly 8 weeks after her fall. It was ironic that I was actually eating at her restaurant when she fell, the family knew me so I left my meal and was able to diagnose the fracture within minutes of her fall but she will wait 2 months for treatment.
We do have an X-ray machine and a nurse trained to take the pictures but must do our own interpretation. There is also an excellent ultrasound machine but again we have to do our own scans, I'm learning slowly.

The working day starts at 8:30 except on Thursday when we start at 8:00 with each of us taking it in turn to provide a presentation on a subject of recent interest. We have a half hour to discus any problems from the previous day and then go down to the wards to see our individual patients and catch up on paperwork and reports. I then do a morning clinic everyday except when I am anaesthetising.  Three days a week these are in the hospital but on Mondays and Thursdays in peripheral clinics. The Monday clinic is at Half Tree Hollow which is a rather dull dormitory community high on the hill above Jamestown it’s a busy clinic with 20 or so patients but usually fairly straightforward. On alternate Thursdays I attend the Levelwood and Sandy Bay clinics. These are rather ramshackle buildings high on the mountain and often in cloud but with stunning views on clear days. Despite being only a few miles from Jamestown there are patients who hardly ever go to the “town” they all speak the Queen’s English but some of them are barely intelligible. They are stubbornly independent and quite stoical. One lady had fallen and fractured her wrist but waited three days to see me in the clinic rather than come to the hospital. Monday afternoons I run clinic at the Community Care Complex which is a large modern building which provides residential and nursing home care for the elderly. Tuesday afternoons I assist the dentist with sedation for the large proportion of the population who seem to be needle phobic. Wednesday pm is my diabetes clinic, Thursday is catch up time and prison visits and Friday is my mental health clinic at the end of which I am more than ready for sundowners at Donny’s on the waterfront.

We are on-call one day in four but always have to be prepared to help out with an anaesthetic in an emergency especially for maternity cases. Out of hours is when life becomes interesting because whatever the problem you have to find a way of managing you cannot delegate to someone else. When a man died suddenly and unexpectedly I felt unable to provide a death certificate and suggested a post mortem, the next day I carried out my first post mortem. We have to recognise our limitations and acknowledge that some problems are beyond our resources. Last weekend a man was admitted with a leaking aortic aneurism, we did not attempt resuscitation but gave enough morphine to keep him comfortable and ensure that he died peacefully.

For non-emergency problems there is always the option of sending patients to the UK or Capetown for definitive care. This is a very expensive option from the managers point of view because not only must the island fund the cost of the treatment, in South Africa at least but also the cost of travel and accommodation while the patient is away.  Each Thursday morning we have a meeting to discuss priorities and decide which patients justify referral. Not an easy task, there are some guiding principles written down but it is never an straightforward decision.

The most frustrating aspect of work here is the attitude of many of the islanders particularly the older generation who are reluctant to take any responsibility for their health. One of the major reasons for the high prevalence of diabetes is the poor diet and lifestyle of the islanders. Obesity is far worse than in the UK and accepted as the norm. I’ve even had patients of ideal body weight concerned that they are too thin and cannot put on weight. That said I’ve some sympathy for their attitudes, fresh produce is expensive and not always available and the opportunities for exercise are limited if you cannot manage steep hills. Most roads and paths go either up or down there are very few opportunities for easy walking. The problem of attitude to health care remains and includes an assumption that it is the doctor’s duty to care for your health and that it is the Government’s duty to improve health care. They do not want to know anything about the details of their medical problems and often cannot provide a reasonable account of their symptoms or the history of their condition. A common comment about problems they have had before is that the doctor didn’t tell me anything, I’m suspect there is some truth in this but I’m sure that the real problem is that they didn’t ask or didn’t want to know especially when the message was unwelcome.

Minor niggles aside most of the patients are appreciative and supportive, I’m enjoying the challenge of my extended General Practice role and developing new skills though where I will use these skills next is another matter.